Improving Children’s and Their Visitors’ Hand Hygiene Compliance

Background Numerous interventions have tried to improve healthcare workers’ hand hygiene compliance, however little attention has been paid to children’s and their visitors’ compliance. Aim To increase children’s and visitors’ compliance using interactive educational interventions. Methods This was an observational study of hand hygiene compliance before and after the introduction of educational interventions. Qualitative data in the form of Questionnaires and interviews was obtained. Findings Hand hygiene compliance increased by 21.4% (P <0.001) following the educational interventions, with children’s compliance reaching 40.8% and visitors’ being 50.8%. Compliance varied depending on which of the ﬁve moments of hygiene was observed (P<0.001), with the highest compliance after body ﬂuid exposure (96%). Responses from questionnaires showed educational interventions raised awareness of the importance of hand hygiene (69%, 57%) compared to those who had not experienced the educational intervention (50%). Conclusion Educational interventions may result in a significant increase in children’s and visitors’ hand hygiene (P <0.001).


Statistical analysis 79
The data were analysed using SPSS statistic software (IBM SPSS statistic v. 21) and 80 GraphPad Prism6. HHC rates composed of simple frequency counts and Chi-square 81 tests. The questionnaire responses were collated in categories inherent in the questions 82 themselves, compared using simple frequency counts and grouped into themes. 83

Results 85
Baseline 86 A total of 525 HH opportunities of patients and visitors were monitored, and the overall 87 compliance rate was 157/525 (30% , Table IA: proportion complied). HHC was low, 88 particularly for children (10%). This rate was significantly different from that of their visitors 89 (26%: P< 0.05). There was also a significant difference in HHC dependent on the moment 90 of HH, irrespective of whether they were children or visitors (P< 0.001). The lowest level of 91 compliance was observed after contact with patient surroundings (13%), and the highest 92 was after exposure to body fluid (100%). Similarly, HHC of patients and visitors depended 93 on the ward that they were on (P = 0.31) and were significantly different dependent on the 94 time of day (P <0.001). 95

Post intervention phase 96
1437 HH opportunities were observed. HHC increased by 24.4% compared to the baseline 97 phase, and was significantly different between (i) children and visitors (P<0.01), (ii) the 98 moments of contact providing the opportunity, (iii) the type of paediatric ward observed, and 99 (iv) the intervention used (P< 0.001) ( Table IB). The higher HHC in the afternoon shift was 100 not significantly different from the morning shift (P = 0.29). HHC of patients and visitors in 101 both intervention groups (but not the control group) was significantly different to the baseline 102 phase HHC (P <0.001). The control group had similar HHC during the intervention phase 103 (30.1%) compared to the baseline (32.3%). Interestingly HHC improvement was greatest 104 after the intervention session using the Glo-yo, and this was a statistically significantly 105 difference (P <0.001). 106

Handwashing 109
Of the 62 children and visitors approached, 31 agreed to participate in the educational 110 intervention. The Glo-yo group included 16/31 (51.6%) of the participants (9/16 were 111 patients). The Video group included 7/31 (22.5%) of the participants (5/7 patients). The 112 control group included 8/31 (25.8%) of the participants (1/8 patients) (who only had access 113 to HHC leaflets). All children were given a questionnaire to complete to determine their 114 perception of the intervention session. 115 Children reported that the educational interventions raised their awareness of hand hygiene, 116 with the Glo-yo intervention prompting a higher proportion of the participants to indicate that 117 they strongly agreed with this ( Figure 1). 118 119

The intervention session helped increase children's knowledge and understanding of 120 germs and handwashing 121
The questionnaire sought participant feedback on; A. why we wash our hands, B. germs 122 and bacteria, C. when to wash hands, and D. parts of hands that are difficult to wash. The 123 answers varied between intervention and subcategory of question. The Glo-yo intervention 124 group agreed strongly with respect to all question subcategories ( Figure 2). 125 Almost two thirds of participants in the Glo-yo and MLT intervention groups strongly agreed 126 that the session and both training aids focused on why we wash our hands (62.5% and 127 71.4%), but 100% of the control group merely agreed with this ( Figure 2a). When asked 128 about whether the intervention increased knowledge about bacteria and germs, 33.3% of 129 the participants in the Glo-yo group highly agreed and 100% of the Video group agreed, 130 which contrasted with the control group, who were 100% neutral on this point (Figure 2a). 131 hands, 88% of the Glo-yo group strongly agreed, whereas 71% of the Video group and 88% of control group were neutral (Figure 2c). Finally, when asked whether the intervention 134 session increased the knowledge and understanding of the parts of hands that are difficult 135 to wash, 69% of the Glo-yo group, 43% of the Video group and only 13% of the control group 136 strongly agreed. Indeed, a small proportion of the participants of the Video and controls 137 disagreed with this (Figure 2d). to reach 58.3%. Although this is considered a low compliance rate, it is significantly higher risk to patients, especially those in close and direct contact with patients (Dancer, 2009). 158 Another high increase in HHC was observed 'after contact with patients'. This was mainly 159 observed in visitors, increasing from 23.7% to 70.8%, to reach a level >20% higher than 160 previous observational studies ( Randle et al., 2010). No study was found that looked at HHC 161 of patients before a meal, in this study it was observed that compliance at this opportunity 162 at the intervention phase was as high as 65 %. 163 This study indicates that HHC is better than previously reported, and provides evidence of 164 a significant increase in HHC during intervention (P <0.001). The Glo-yo session proved 165 the most successful intervention and was able to raise awareness of the importance of HH, 166 with parents strongly agreeing that the Glo-yo session will improve their child's hand